Subsistema de composici´on

Breast exam: Sitting: Inspect in four separate positions: 1) sitting with arms at her side, 2) sitting with both arms raised above her head, 3) sitting with hands pushing on hips and elbows out, 4) patient leaning forward: inspect for size and symmetry, visible masses/contour changes, skin retraction, erythema, dimpling, nipple retraction/inversion/ulceration/size & shape, peau d’orange around nipple and elsewhere. Palpation of axillary, infraclavicular, supraclavicular nodes. Supine (with pillow under shoulder), each breast examined separately, drape other breast, small circular motions covering an area of approximately 1 square inch  divide into light, medium and deep palpation and perform in all four quadrants. Can denote position of lumps by clock position with cm distance from nipple. Nipple squeeze to try to exude any fluid from the nipple (ask patient to squeeze nipple herself). Watch for dimpling, bloody nipple discharge and inflammation.

Mammography: Yearly mammography screening of proven benefit from age 50. Benefit as a screening test equivocal from age 40 in the general population but is recommended if there is a positive family history of breast cancer. Breast cancer in two first degree relatives (parents, siblings, children) is an indicator for yearly mammography starting at 5-10 years before youngest family member’s presentation. 98. 60 year old male, difficulty walking. Perform a neurological exam.

See neurological exam in question #5.

History: Patient ID: Planned pregnancy? Status of any relationships at present including relationship with the child’s father. Social supports (family, friends, boyfriend), do they know? Are they helping? Employment/financial/educational status of the patient, does the patient feel prepared to raise a child? Provisions for care of child when born? GTPAL (number of gestations, term pregnancies, premature births, abortions, live children), history of problems, if any, with previous pregnancies. Current pregnancy, establish gestational age (GA) by last menstrual period (LMP) if regular periods and sure dates (if unsure a dating ultrasound would be needed). The GA is the number of weeks from the first day of the LMP. The EDC is first day of LMP + 7 days – 3 months. Smoking (prepared to quit?), alcohol (no alcohol during pregnancy), illicit drugs, diet, exercise, medications (avoid during pregnancy: including over the counter). Diabetes, family history of inherited disorders, heart disease, circulatory problems, renal disease, hypertension. Menstrual history, regularity of cycles, how long has patient not used contraception. Any morning sickness, vaginal bleeding? Past medical and surgical history, medications, drugs/alcohol, smoking, allergies, family history, review of systems.

Psychiatric: Cover mnemonic for major depression. MSIGECAPS: mood (depressed), sleep (increased or decreased…if decreased, often early morning awakening), interest (decreased), guilt/worthlessness, energy (decreased or fatigued), concentration/difficulty making

decisions, appetite and/or weight increase or decrease, psychomotor activity (increased or decreased), suicidal ideation – positive diagnosis of major depression requires five of these over a 2 week period, one of the five must be loss of interest or depressed mood. Symptoms do not meet criteria for mixed episode, significant social/occupational impairment, exclude substance or GMC, not bereavement.

Physical: vitals, weight, height, palpation of neck and thyroid gland, fundoscopic exam, check lid lag, reflexes, cardiopulmonary exam, breast exam, abdominal exam. Palpate uterus, measure symphysis-umbilicus distance. Doppler for fetal heart (may not detect until 10 weeks). Vaginal bimanual and speculum exam (cervix should be closed). Pap smear (if none in last 6 months, use speculum, not brush in os), swab cervix for cultures (GC, chlamydia).

Investigations: CBC, lytes, INR/PTT, urea, creatinine, urinalysis, ECG. Blood group and type, Rh antibodies, VDRL and HbsAg routine, rubella titer, HIV serology offered, serum folate, urine dip, microscopy and culture, TB skin test in patients from an endemic area, genetic testing as indicated on history or for sickle cell in blacks. Triple screen (MSS)  MSAFP, ßhCG, uE3  Trisomy 18, Trisomy 21, NTD (at 16 weeks). Amniocentesis at 15-16 weeks for alpha-fetoprotein and acetyl cholinesterase. Chorionic villus sampling (10-12 weeks) should be offered given the patient’s age. Fetal ultrasound.

Counseling: Discuss risk of Down’s syndrome due to maternal age, value of fetal genetic testing. Recommend daily pregnancy vitamin preparation, milk and healthy diet. Do not increase food intake dramatically – excessive weight gain not recommended, 2-3 lbs per month for a total of 25-30 lbs gain in weight ideal. Do not diet during pregnancy. Continue normal activities and customary exercise. No alcohol, no smoking, no medications of any kind unless discussed with MD. Control morning sickness with small meals and bland foods. Lying on side decreases swelling and discomfort. Hemorrhoids, backache, heartburn, increased vaginal discharge are common. Follow-up every 4 weeks until 32 weeks, then increase to every 2 weeks. Call if any concerns or troubling symptoms, especially abdominal pain, vaginal bleeding, persistent headache, illness or infection.

100. 60 year old female with bloody vaginal discharge. Take a history.

History: Name, age, occupation. Think about: blood dyscrasias, thyroid dysfunction, malignancy, PCOS, endometriosis, PID, fibroids, unopposed estrogen, or polyps. Onset of bleeding, frequency, estimate quantity (number of pads), color, consistency of discharge, associated pain, vaginal discomfort, cramping. Previous episodes, history of fibroids, polyps, PID, PCOS. Post coital and rectal bleeding. Weight loss, night sweats, fatigue. History of easy bruising/bleeding, inherited blood coagulation disorders. Age of menarche, age of menopause, age of first sexual activity. Use of hormonal replacement therapy, which preparation? History of fibroids, reproductive tract cancers, last Pap smear. Pregnancy history. Medications, drugs/alcohol, smoking, past medical history, surgical history, family history, review of systems.

101. 30 year old man with hematemesis and abdominal pain in the emergency department. BP 80/50, tachycardia. Manage. Resuscitate as in question #6. Consult gastroenterology for immediate endoscopy.

102. Pregnant woman, 36 weeks gestation, has proteinuria and BP 150/85 (pre-gestational BP 110/65). Manage. See question #46.

103. A mother is worried that her 1 year old looks pale. Take a history. Finding: breast fed for the first 2 months, then 2% milk. Q: What is the most likely diagnosis? What investigations would you order?

History: Name, age. Feeds and feeding history (esp. fruit juice, excess milk). Growth pattern: weight loss? Diarrhea? (consistency, color, quantity and frequency), blood in stool, melena stools, concurrent illness, vomiting, fever, anorexia, difficulty breathing, lassitude, dry mouth/eyes, low urine output, illness affecting other children in the family or adults. Recent immunization, travel, antibiotics. Medications, past medical history, allergies, birth history, pregnancy problems, maternal illness during pregnancy, family history, review of systems. Most likely diagnosis: Iron deficiency anemia (most common cause of childhood anemia). Typically in bottle-fed infants (6-24 months) receiving large volumes of cow’s milk  should add iron-fortified cereal and iron rich foods starting at 6 months.

Investigations: CBC with peripheral smear, lytes, urea, creatinine, INR/PTT, serum ferritin, albumin.

104. Elderly man with creatinine 1000. Take a history. Q: Give a differential diagnosis. What investigations would you order? History: Patient ID. suprapubic pain, pain on urination, frequency, urgency, frank blood in the urine (globular clots from bladder or string shaped clots from ureters), color of urine, difficulty initiating or maintaining urinary stream, renal pain, groin pain. Provoking factors. Associated symptoms including saddle anesthesia, loss of bowel control. History of recent UTI, STDs, TB exposure, pelvic irradiation, bleeding diathesis, smoking. Fever, chills, nausea, fatigue. Previous renal colic/diagnosed nephrolithiasis? History of hypercalcemia, hypertension. Malignant symptoms: night sweats, weight loss, fatigue. Medications, drugs (NSAIDs, anticoagulants)/alcohol, smoking, past medical history, past surgical history, family history (polycystic kidney disease?), review of systems.

Differential diagnosis:

1. Pre-renal: Hypovolemia, poor cardiac output, renovascular disease, NSAID/ACEi use, liver failure.

2. Renal: Vascular  malignant HTN, cholesterol emboli, HUS/TTP; Tubulo-interstial  ATN (ischemic/toxin  endogenous/exogenous), AIN; Glomerular (< 5%). Causes: X-ray contrast, myoglobinuria, acute glomerulonephritis, DIC, pyelonephritis, intrarenal precipitation in hypercalcemia, myeloma.

3. Post-renal: Obstruction: upper (clot, tumor, stone, external compression), lower (BPH, clot, stone, stricture, autonomic dysfunction). Investigations: CBC, lytes, urea, creatinine, phosphate, ionized Ca++_{, magnesium, INR/PTT, AST, ALT, ALP, GGT, prostate specific antigen,}

CK-MB, troponin, ABG. Urinalysis: microscopy, dip, culture and sensitivity. Abdominal x-ray, abdominal pelvic ultrasound. Post-void catheterization. (Avoid IVP due to dye).

105. 1 year old boy with 6 months diarrhea. Take a history. Q: Give a differential diagnosis. See question #50.

106. 58 year old lady in hospital 4 days post-op hysterectomy for fibroids. Agitated, had tactile hallucinations the previous night. Take a history. Finding: history of alcoholism. Q: What is the most likely diagnosis?

History: onset of hallucinations, duration, description. Tactile hallucinations or bugs crawling on skin or on ceiling suggest alcohol withdrawal. Associated fever, agitation, sweating, tremor, decreased level of consciousness, seizure? Any problems with surgical recovery, wound healing, mobilization? Amount of alcohol consumed at home. History of alcoholism, leg swelling, SOB, chest pain. Current state. Post-op medications (morphine, Demerol) – previous bad reactions to these or to antibiotics? Previous episode like this one? Past medical history, medications, drug and alcohol use, smoking, allergy, family history, review of systems.

Most likely diagnosis: alcohol withdrawal.

107. Young man with a swollen cervical lymph node. Perform a focused physical exam. Q: CXR shows mediastinal widening with perihilar nodes. Describe. Give five features on history which would be helpful for diagnosis.

Physical exam: vitals, jaundice, nutritional status, buccal mucosa, teeth, breath (hepatic fetor), parotid hypertrophy, glossitis, inspect chest for telangectasia, gynecomastia, loss of axillary hair. Hands: palmar erythema, clubbing, Dupuytren’s contracture, wasting of hand intrinsics. Palpate for lymph nodes in the neck, supra and infra-clavicular, axillae, groin. Examine the oral cavity and pharynx. Check for rashes. Abdominal exam (supine): see question #29.

Differential diagnosis: lymphoma, leukemia, viral infection (mononucleosis, HIV, EBV), inflammatory autoimmune disease (sarcoidosis, lupus), serum sickness (severe allergic reaction short of anaphylaxis), TB, liver disease with portal hypertension.

Five features on history helpful for diagnosis: viral prodrome, family history of sarcoid, lymph nodes painful, bone pain, pruritis, weight loss.

108. Female patient found to have a nodule on routine CXR. Perform a focused physical exam. Q: Give a differential diagnosis. What investigations would you order?

Cardiopulmonary exam as in question #13 and #24. See also question #49.

Investigations: old CXR for comparison (if lesion is old and unchanging, interventions are less aggressive, calcification is also associated with benign lesions such as old granulomas), CT chest with CT guided needle biopsy, sputum for cytology and acid-fast staining (TB), TB skin test, bronchoscopy with biopsy and washings if lesion seen, open biopsy or lobectomy.

Algorithm: solitary nodule  previous CXR  benign or unchanged (repeat in q3-6months for 2 years if unchanged observe, if changed at any time continue…), malignant or changed  CT thorax: cancer (stage and treat), calcification (observe), no diagnosis  bronchoscopy or transthoracic needle aspiration  still no diagnosis (resect for diagnosis), inflammatory (treat cause), cancer (stage and treat).

109. 60 year old male slipped and fell 6 days ago. Comes to you because of hemoptysis. Perform a focused physical exam. Finding: positive Homan’s sign. Q: What is the most likely diagnosis? Give a plan form management.

Cardiopulmonary exam as in question #13, plus additional attention to calf size, tenderness, redness and pleuritic chest pain.

Homan’s sign: pain in the calf on dorsiflexion of the foot – indicates thrombophlebitis. Check that trachea is midline. Is the patient on DVT prophylaxis or anti-coagulation?

Most likely diagnosis: pulmonary embolus.

Specific investigations for PE: CT chest (only shows clinically significant PE), V/Q scan (conclusive when is shows high or low

probability), pulmonary angiogram (gold standard but invasive), ECHO, and serial (q2d) leg Dopplers for presence of DVT above the knee. Others: CXR (often normal, Hampton’s hump, Westermark’s sign, rarely dilatation of proximal PA), ECG (sinus tachycardia, S1Q3T3), ABG

(PaO2 usually decreased, PaCO2 decreased due to increase in overall minute ventilation, increased A-a gradient), D-dimer. See also question #17.

Treatment: if suspicion of PE is high, anticoagulate before waiting for these tests with heparin 7500 U IV bolus (80 U/kg), then infuse at 1200 U/hr (18 U/kg/h). Measure PTT q6h, adjust dose for PTT 70-90s (2.5-3 times normal baseline). Start coumadin, to INR 2-3, continue coumadin for 3 months.

110. Telephone in room. Mother calls because her child has just ingested a caustic cleaner. Manage over the phone. Q: What do you do after hanging up the telephone? Give a plan for management.

See question #52.

111. Telephone in the room. Physician in a peripheral center calls wishing to transfer an unstable patient who has been in a motor vehicle accident. Manage over the phone. Q: CXR shows opacification of the right lung. What is your diagnosis? Give the immediate management of this problem.

Over the telephone: Physician’s name, name of center, patient’s name. Injuries, investigations done, vitals, lab values. GCS, is patient intubated? Peripheral physician must not transfer patient until he is stabilized, i.e. good BP, good oxygen sats, bleeding controlled, blood products given as needed. Estimated time of arrival? Physician accompanied?

Treatment: Chest tube in ER, drain hematoma and connect to suction through a bubble chamber. Consult thoracic surgery, prepare patient in case of immediate OR.

112. Young woman with bilateral migratory arthritis of recent onset. Take a history. Q: Give a differential diagnosis. What investigations would you order?

Note: Migratory arthritis suggests gonococcal infection.

History: Patient ID. Onset of arthritic symptoms, durations, joints affected, chronology. Associated fever, malaise, fatigue, rash, abdominal pain and cramps, vaginal discharge, pain with urination, dyspareunia (painful intercourse). History of arthritis (rheumatoid, osteoarthritis), psoriasis, Lyme disease (camping trips), Reiter’s syndrome, ankylosing spondylitis, sexually transmitted diseases including PID. Sexual history: present partners, number of partners, fidelity of partner(s), use of condoms. Medications, drugs/alcohol, smoking, allergies, past medical history, family history, review of systems.

Differential diagnosis: gonococcal arthritis, psoriatic arthritis, Lyme disease, Reiter’s syndrome, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, gout.

Investigations: CBC, ESR, lytes, urea, creatinine, INR/PTT, blood cultures. Cervical swab for culture and sensitivity. Joint aspirate for microscopy and culture.

Sample Q’s